A behavior screening questionnaire improves problem identification in veterinary primary care with implications for patient health

Margaret M. Duxbury Veterinary Behavior Specialties of Minnesota, Minnetonka, MN

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Helen Sobczynski Veterinary Behavior Specialties of Minnesota, Minnetonka, MN

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Kristi Flynn Department of Veterinary Clinical Sciences, College of Veterinary Medicine, University of Minnesota, Saint Paul, MN

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Aaron Rendahl Department of Veterinary and Biomedical Sciences, College of Veterinary Medicine, University of Minnesota, Saint Paul, MN

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 PhD

Abstract

OBJECTIVE

To compare how often owners identified concerns about their pets’ behavior during routine examinations in 2 test conditions (voluntarily or when completing a questionnaire), and to test the efficacy of a simple behavior screening questionnaire to be used by practicing veterinarians.

ANIMALS

Privately owned dogs and cats presenting for routine examinations to 1 of 2 primary care clinics.

METHODS

The study was conducted in 2 sequential phases. In Phase 1, veterinary staff recorded whether pet owners or veterinarians inquired about behavior during routine examinations. In Phase 2, a different set of pet owners completed a short behavioral screening questionnaire as they waited for the veterinarian. We compared the 2 phases for how often behavior concerns were identified, the types of concerns, the pets’ ages, and the owners’ levels of satisfaction and desire for help.

RESULTS

Dog and cat owners were more likely to identify behavior concerns when prompted than they were to volunteer this information, especially for older patients in which behavior changes may be the first sign of disease. Most owners were satisfied with their pets’ behavior, though owners were more likely to be unsatisfied with certain identified concerns. Owners who were dissatisfied were much more likely to want help.

CLINICAL RELEVANCE

A behavior screening questionnaire enhances detection of behavior problems that may have medical implications and impact the security of the pet in its home. A behavior screening questionnaire can elevate standard of care by enabling veterinarians to quickly assess behavior during every examination.

Abstract

OBJECTIVE

To compare how often owners identified concerns about their pets’ behavior during routine examinations in 2 test conditions (voluntarily or when completing a questionnaire), and to test the efficacy of a simple behavior screening questionnaire to be used by practicing veterinarians.

ANIMALS

Privately owned dogs and cats presenting for routine examinations to 1 of 2 primary care clinics.

METHODS

The study was conducted in 2 sequential phases. In Phase 1, veterinary staff recorded whether pet owners or veterinarians inquired about behavior during routine examinations. In Phase 2, a different set of pet owners completed a short behavioral screening questionnaire as they waited for the veterinarian. We compared the 2 phases for how often behavior concerns were identified, the types of concerns, the pets’ ages, and the owners’ levels of satisfaction and desire for help.

RESULTS

Dog and cat owners were more likely to identify behavior concerns when prompted than they were to volunteer this information, especially for older patients in which behavior changes may be the first sign of disease. Most owners were satisfied with their pets’ behavior, though owners were more likely to be unsatisfied with certain identified concerns. Owners who were dissatisfied were much more likely to want help.

CLINICAL RELEVANCE

A behavior screening questionnaire enhances detection of behavior problems that may have medical implications and impact the security of the pet in its home. A behavior screening questionnaire can elevate standard of care by enabling veterinarians to quickly assess behavior during every examination.

Introduction

Annual wellness examinations enable veterinarians to identify health concerns early to provide effective treatment. Animal behaviors provide important insight into their health and welfare. In fact, current veterinary practice guidelines call for veterinary examinations to include a life stage–specific assessment of a pet’s behavior and environment,1,2 yet previous studies have shown that most veterinarians do not ask questions pertaining to behavior during routine examinations of adult dogs and cats.3,4

Behavior problems are a leading cause of relinquishment and euthanasia of both dogs and cats.5,6 They diminish the human-animal bond7 and may impact the quality of life of the entire family unit.8,9 As a result, patients with behavior problems may be lost to veterinary care. Owners with strong bonds with their pets are more likely to be invested clients, consult with their veterinarians frequently, pursue advanced levels of care, and adhere to doctors’ recommendations.10

Additionally, behavior changes often indicate purely physical concerns. Research suggests that up to 80% of pets with behavior problems such as aggression, pica, and noise sensitivity have underlying painful conditions, and treatment of these conditions improves or resolves the problem behavior.1113 Another study14 found that pruritic dogs were less trainable and more likely to exhibit signs of fear, anxiety, and aggression. A 2020 case report15 describes the complete resolution of aggression in a 7-year-old mixed-breed dog in response to a dietary change to a gluten-free, hydrolyzed protein diet. Excessive licking of surfaces has been linked to gastrointestinal disorders.16 Several human studies have documented 2-way interactions between pain and anxiety: pain can induce anxiety, and anxiety can magnify the perception of pain.17 The strong interplay between health and behavior makes it crucial to assess both during annual wellness examinations.

While early identification of problematic behaviors is beneficial, it can be a challenge for both pet owners and veterinarians to identify these concerns.18 Behaviors that are problematic at the veterinary clinic may never be expressed in the pet’s normal environment. The reverse is also true, and owners may have significant concerns about a pet whose behavior appears normal at the veterinary office. Pet owners may not consider their veterinarian as a source of help with behavior.19 They may hesitate to interrupt the flow of a health-focused appointment with a question about behavior or have their pet labeled as “aggressive” or “anxious.”

Pandemic-related schedule crowding, staff shortages, and an impatient mass of waiting clients may make veterinarians reluctant to “open the box” to questions about an open-ended topic such as behavior, especially if they feel ill-equipped to provide solutions. Many veterinarians are reluctant to discuss behavior issues with clients due to their own lack of knowledge, citing veterinary education that poorly prepared them to discuss or manage behavior cases.3,4,2024 Behavior cases may receive less follow-up than cases related to physical health.21 A set of short, concise, and relevant screening questions could facilitate better problem identification, inclusion of behavior in a patient’s problem list, and a time line and process for workup and treatments that cannot be addressed within the scope of a routine annual examination. Other studies have examined how infrequently veterinarians inquire about behavior during routine veterinary examinations.4,20,24 The purposes of this study were 2-fold: (1) to compare how often owners identified concerns about their pets’ behavior during routine annual examinations in 2 test conditions (voluntarily or when completing a questionnaire), and (2) to test the efficacy of a simple behavior screening questionnaire to be used by practicing veterinarians.

Methods

Animals included in this study were privately owned dogs and cats presenting to 1 of 2 American Animal Hospital Association–approved hospitals near a major metropolitan area. Hospital 1 was a privately owned standalone clinic with 2.5 veterinarians seeing primary care patients. Hospital 2 was a 4.5-veterinarian primary care service inside a university teaching hospital. The hospitals had similar yearly caseloads (estimated 3,500 for Hospital 1 and 2,600 for Hospital 2). Both practices saw more dog than cat patients, though the university practice saw a higher percentage of cats. Owners were primarily families of middle-class income (Hospital 1) or affluent and middle-class incomes (Hospital 2). Most patients were sexually altered except those that were being allowed to mature before surgery. The breed makeup of each practice was primarily Labradors or Golden Retrievers and their crosses, pit bull–type dogs and their crosses, and a variety of small breeds. Cats were primarily domestic short-, medium-, or longhair cats.

This study examined dogs and cats presented to the study hospitals for routine wellness examinations. Recheck, diagnostic, and “sick pet” examinations were excluded. Participating pet owners gave written consent to take part “in a study examining the type of concerns raised by pet owners during wellness exams.” Individual identifying information was not recorded for any participant.

For ease of implementation by veterinary support staff and to minimize the disruption of normal clinic procedures, the study was performed in 2 sequential phases, each with a separate group of owners and pets. Veterinarians in each phase were instructed to conduct their routine examinations as usual without alterations. Support staff in both locations included veterinary technicians and veterinary assistants. In Hospital 2, support staff also included veterinary students. In both phases, support staff spent approximately 5 to 15 minutes in the room taking a brief history (eg, any vomiting, diarrhea, coughing, sneezing, etc), checking on refill status for preventative medications, and inquiring about optional vaccines. Temperature, pulse, and respiration measurements were not performed. A consistent support staff member remained in the examination room with the doctor to observe the wellness examinations as they occurred.

Phase 1

Staff used a preprinted standardized recording sheet to note whether behavioral concerns were voluntarily raised by pet owners at any time during the initial history or the wellness visit with the doctor, whether the doctor offered intervention for client-raised concerns, and whether the veterinarian inquired separately about behavior.

Concerns raised by the owner or veterinarian were then categorized into the following general categories used in Phase 2 to screen common areas of concern: undesired elimination, signs consistent with cognitive dysfunction, separation anxiety, fear of loud noises and storms, aggression to any person, conspecific aggression, or overgrooming.

Phase 2

Veterinary support staff (veterinary technicians, veterinary assistants, and veterinary students in Hospital 2) offered an anonymous behavior screening questionnaire that was completed by pet owners. Because all owners completed the questionnaire, staff did not record whether the veterinarian separately inquired about behavior concerns.

During the time between check-in and when the veterinarian entered the examination room, owners were invited to fill out an 8-question, yes/no behavior screening questionnaire, which took approximately 2 minutes to complete (Supplementary Material S1). The authors developed Questions 1 through 6 to screen for problems in common categories of concern. For dogs, these categories included house soiling, signs suggestive of canine cognitive dysfunction syndrome (CCDS), separation anxiety, fear of noises, aggression toward humans, and aggression toward dogs. Cat categories included house soiling, nighttime howling or disorientation, chewing, ingesting or scratching household objects, whether the cat appeared to like other cats in the house, aggression directed at humans, or overgrooming. The cat-specific questionnaire also asked whether the client was planning on adding another cat or kitten to the household.

If pet owners had appointments for multiple animals, they were encouraged to fill out a questionnaire for each pet. Both hospitals required individual full appointment slots for each pet. For both phases, a summary variable was created to capture whether any behavioral concerns were raised by the owner.

Questions 7 and 8 on the Phase 2 questionnaire examined owner satisfaction and desire for help. If the pet owner opted for help, the attending veterinarian was encouraged to address the issue. Issue-specific handouts were created and distributed by the authors to aid the attending veterinarians during this process.

Statistical analysis

All analyses were performed separately for canines and felines. All tests were 2-tailed, and statistical significance was set at P < .05.

To explore differences in behavioral concerns by phase and hospital site, response data were averaged at the household level before calculating counts, so some counts are fractional. Confidence intervals were computed using the Wilson proportion test with continuity adjustment, and differences between groups were tested using the 2-sample proportion test with continuity adjustment.

To explore differences in behavioral concerns by age, the animal-level data were used, as these variables were measured on the individual pets. For these analyses, CIs on the proportions of positive responses were computed using the Clopper-Pearson method and differences between groups were tested using the Fisher test. To explore differences in age between the phases and hospital settings, a 2-way ANOVA was performed.

To explore relationships between reporting “satisfied” and “wanting help” with responses to the other questions, univariate analyses were first performed using the Fisher test and then followed by multivariate analyses using logistic regression with all other questions as predictor variables.

Results

Both study hospitals reported that 95% to 97% of clients agreed to participate in the study. Phase 1 veterinary support staff recorded voluntary reporting from owners of 109 dogs and 103 cats. Three dog owners had separate appointments for 3 dogs, and 4 dog owners had separate appointments for 2 dogs. The remaining 92 dog owners had an appointment for 1 dog. One cat owner had separate appointments for 3 cats, and 13 cat owners had separate appointments for 2 cats. The remaining 74 cat owners had an appointment for 1 cat.

In Phase 2, a different set of pet owners completed 105 dog questionnaires and 103 cat questionnaires. Thirteen owners had separate appointments for 2 dogs and completed individual questionnaires for each. The remaining 79 dog owners had a single dog appointment and completed 1 questionnaire each. Five cat owners had separate appointments for 3 cats and completed individual questionnaires for each. Eighteen cat owners had separate appointments for 2 cats and completed individual questionnaires for each. Fifty-two cat owners had a single cat appointment and completed 1 questionnaire each. Across phases and species, there were 213 responses from Hospital 1 and 207 responses from Hospital 2, and there were no statistically significant differences between hospital settings in the frequencies of identified behavior concerns.

There was also no statistically significant difference in the ages of the survey subject pets between either hospital settings or phases. The mean age for dogs was 6.1 years in Phase 1 (SD, 4.2; median, 5) and 6.6 years in Phase 2 (SD, 4.1; median, 6). The mean age for cats was 7.1 years in Phase 1 (SD, 4.7; median, 7) and 7.5 years in Phase 2 (SD, 5.1; median, 7). For further analyses, both dogs and cats were grouped into 1 of 4 age groups: < 1 year of age, 1 year or older and < 4 years of age, 4 years or older and < 9 years of age, or > 9 years of age. The breed, sex, and spay or neuter status was part of the medical record for each examined pet, but that information was not specifically included in the questionnaire and not included in the data analysis.

To anticipate the potential problem of owners misinterpreting communication signals between household cats, Phase 2 cat owners were asked only if the cats in the household appeared to like each other. This question was ultimately discarded because it broke the format of other questions, did not distinguish single versus multiple cat households, and was not directly comparable to any Phase 1 reports of conflict. Two other questions on the cat questionnaire (“Do you plan to add another cat?” and “Does your cat chew or ingest household objects?”) were discarded because we could not ensure they were accurately tracked in Phase 1.

One cat questionnaire was excluded because the pet owner left all behavioral questions blank. Three dog questionnaires had no response circled (yes/no) for the question asking whether the pet owner needed help, and these responses were treated as if the pet owner had circled “no.”

Dog owners

Dog owners were more likely to identify behavior problems on the questionnaire than they were to bring them up voluntarily without prompting, with 19.9% of owners reporting at least 1 problem in Phase 1, compared to 74.5% in Phase 2 (P < .0001; Figure 1). Still, most dog owners were satisfied with their dog’s behavior (Phase 2 only, 88/105 [83.8%] dogs), and owners were concerned enough to want help improving or changing a behavior for only 27 of 105 (25.7%) dogs. Those who were not satisfied with their dog’s behavior were much more likely to want help (13/17 [76%]) compared to those who were satisfied (14/88 [16%]; P < .0001).

Figure 1
Figure 1

Dog owners presenting patients for routine annual examinations report far fewer behavior concerns voluntarily than when using a screening questionnaire. Q1 = House soiling; *P < .0001. Q2 = Disoriented/confused. Q3 = Separation anxiety; *P = .028. Q4 = Fear of noises; *P < .001. Q5 = Aggression to humans; *P = .0046. Q6 = Aggression to dogs; *P = .0001. Q7 = Satisfied. Q8 = Want help. Any = Any concern identified; *P < .0001.

Citation: Journal of the American Veterinary Medical Association 262, 4; 10.2460/javma.23.07.0405

Specific problems identified more often on the questionnaire than by voluntary reporting included urinating or defecating in the house, being anxious, vocalizing or exhibiting destructive behavior when left alone, being fearful of storms or loud noises, or showing signs of aggression (growling, baring teeth, barking aggressively, nipping, snapping, or biting) directed at either humans or dogs (Figure 1).

For the question, “Does your dog urinate or defecate in the house?” owners were more likely to answer “yes” than to voluntarily bring this concern up on their own (3.9% in Phase 1, compared to 28.3% in Phase 2; P < .0001; Figure 1). Dogs with undesired elimination were more likely to have dissatisfied owners (29%, compared to 10.8% without this problem; univariate P = .04; multivariate P = .076). In our study, owners with dogs that eliminated in the house also were more likely to want help (35%, compared to 22%); however, this difference was not statistically significant (univariate P = .15; multivariate P = .60).

The screening question for separation anxiety asked, “Is your dog anxious, vocal, or destructive when left alone?” Owners were more likely to report these signs on the questionnaire than to bring them up on their own (3.0% in Phase 1, 12.5% in Phase 2; P = .028; Figure 1.) Owners were also more likely to indicate fear of noises (such as thunder, fireworks, or trucks) on the questionnaire (5% in Phase 1, 35% in Phase 2; P < .0001). Neither separation anxiety (univariate P = 1.0; multivariate P = .14) or fear of noises (univariate P = 1.0; multivariate P = .47) had a statistically significant association with owners being dissatisfied.

Dog owners were asked to indicate whether their dog had ever been aggressive to humans (defined as growling, baring teeth, nipping, snapping, or biting.) Owners were more likely to report this on the survey than to volunteer the information (9.1% in Phase 1, 25.5% in Phase 2; P = .0046; Figure 1). Owners who answered “yes” to this question were more likely to be unsatisfied with their dogs’ behavior than owners of dogs that were not aggressive to humans (35%, compared to 4%; univariate P = .01) and were more likely to want help (45%, compared to 18%; univariate P = .01). However, neither of these relationships maintained significance in the multivariate analyses (P = .22 and P = .062, respectively), likely because this question is strongly associated with the other questions.

Dog owners were asked to indicate whether their dogs react aggressively to other dogs, either on or off leash. Owners answered “yes” to this question more often than they brought it up voluntarily (5.4% in Phase 1, 27% in Phase 2; P = .0001; Figure 1). These owners were more likely to be dissatisfied with their dogs’ behavior than owners of non–dog-aggressive dogs (45%, compared with 4%; both univariate and multivariate P < .0001). These owners were more likely to answer that they wanted help for their dogs’ behavior (42%, compared with 19%; P = .03), though significance was again not maintained in the multivariate analysis (P = .12) due to association with the other problems.

The only question with no statistically significant difference between owner reporting and the survey was a screening questionnaire for signs of CCDS (1.8% in Phase 1, 2.3% in Phase 2; P = .38; Figure 1).

Cat owners

Cat owners were also more likely to identify behavior problems on the questionnaire than they were to bring them up voluntarily, with 14% of owners reporting at least 1 problem in Phase 1, compared to 46% in Phase 2 (P < .0001; Figure 2). Most cat owners were also satisfied with their cat’s behavior (Phase 2 only, 92/103 [89.3%] cats), and owners were concerned enough to want help improving or changing a behavior for only 15 of 103 (14.6%) cats. Problems identified more often on the questionnaire than by voluntary reporting included urinating or defecating outside of the litter box, being disoriented/howling at nighttime, showing aggression to humans, and overgrooming.

Figure 2
Figure 2

Cat owners presenting patients for routine annual examinations report far fewer behavior concerns voluntarily than when using a screening questionnaire. Questions 3 and 4 were discarded. Q1 = House soiling; *P = .034. Q2 = Disorient/howl; *P = .0034. Q5 = Aggression to humans; *P = .0046. Q6 = Overgroom; *P = .018. Q7 = Satisfied. Q8 = Want help. Any = Any concern identified; *P < .0001.

Citation: Journal of the American Veterinary Medical Association 262, 4; 10.2460/javma.23.07.0405

Cat owners were asked, “Does your cat urinate or defecate outside the litter box?” Owners were more likely to answer “yes” to this question than to bring this concern up voluntarily (8% in Phase 1, 21% in Phase 2; P = .034; Figure 2). Owners of house-soiling cats were more likely to be dissatisfied (33%, compared to 5%; univariate P = .0011; multivariate P = .0003) and want help (43%, compared to 7%; univariate P = .0003; multivariate P < .0001).

Cat owners were more likely to answer “yes” that their cat howled at night or appeared disoriented on the questionnaire than to bring this concern up on their own (0% in Phase 1, 12% in Phase 2; P = .0034; Figure 2). They were also more likely to be dissatisfied (33%, compared to 7%; univariate P = .023; multivariate P = .0069) and want help (50%, compared to 10%; univariate P = .0019; multivariate P = .0003).

Cat owners were more likely to identify aggression directed at humans (growling, hissing, biting, and swatting) on the questionnaire than to volunteer that information (8% in Phase 1, 26% in Phase 2; P = .0046; Figure 2). In our study, these owners were more likely to be dissatisfied with their cat, though the difference did not reach statistical significance (19% compared to 8%; univariate P = .15; multivariate P = .46).

The questionnaire was more likely to identify cats that licked, pulled, or chewed their hair to the point where the coat was thin (0% in Phase 1, 8% in Phase 2; P = .018; Figure 2). Though not statistically significant, owners of the 7 cats identified in Phase 2 were slightly more likely to be dissatisfied (1/7 [14%], compared to 10% that did not lick; univariate P = .56; multivariate P = .69) and somewhat more likely to want help (2/7 [29%], compared to 14% that did not lick; univariate P = .27; multivariate P = .21).

For both dogs and cats, not only did the questionnaire better identify the presence of behavior problems, it also appeared to better identify those problems across the animals’ life-spans. (Figures 3 and 4). In Phase 1, owners were most likely to report behavior concerns in dogs aged 1 to < 4 years old. Owners completing the questionnaire in Phase 2 were most likely to report behavior concerns in dogs over 9 years old. In Phase 1, 3 of 26 (12%) owners volunteered any concern about their elderly dogs’ behavior compared to 27 of 34 (79%) owners in Phase 2, for an increase of 67 percentage points. Cat owners in both Phase 1 and Phase 2 reported behavior concerns in cats over 9 years of age more commonly than in other age groups; however, only 4 of 37 (11%) older cats were identified by owner reporting in Phase 1, while 28 of 42 (67%) were identified through the Phase 2 questionnaire, for an increase of 56 percentage points.

Figure 3
Figure 3

Data showing the canine questionnaire to be far better than voluntary owner reporting at identifying behavior concerns in older dogs. Few dogs were < 1 year of age, so this category is excluded. Any = Any concern identified. I1Q1 = House soiling. I2Q2 = Disoriented/confused. I3Q3 = Separation anxiety. I4Q4 = Fear of noises. I5Q5 = Aggression to humans. I6Q6 = Aggression to dogs.

Citation: Journal of the American Veterinary Medical Association 262, 4; 10.2460/javma.23.07.0405

Figure 4
Figure 4

Data showing the feline questionnaire to be far better than voluntary owner reporting at identifying behavior concerns in older cats. Few cats were < 1 year of age, so this category is excluded. Questions 3 and 4 were discarded. Q1 = House soiling. Q2 = Disorient/howl. Q5 = Aggression to humans. Q6 = Overgroom. Any = Any concern identified.

Citation: Journal of the American Veterinary Medical Association 262, 4; 10.2460/javma.23.07.0405

Though not specifically quantified, veterinarians and support staff confirmed that the questionnaires were easy to administer and that clients responded positively to ready-made informational handouts.

Discussion

The behavior screening questionnaire outperformed voluntary owner reporting or veterinary verbal inquiry. The survey consisted entirely of yes/no questions that allowed the veterinary staff to rapidly assess the need for further exploration and, when necessary, schedule a behavioral workup at another time. Each of the behaviors better identified by the questionnaire had potential medical implications. The questionnaire greatly outperformed owner reports in identifying behavior concerns in older pets. Veterinarians who rely on owners to bring up behavioral concerns don’t just lose the chance to address a problem behavior, they miss crucial indicators of medical disease. The authors assert that behavior screening should be a standard component of any medical history, especially for older patients.

Cat owners were far more likely to answer “yes” to the corresponding question, “Does your cat appear disoriented or howl at night?” than to volunteer this information. These signs could be consistent with hyperthyroidism, pain, or other nonspecific medical concerns of elderly cats that should be ruled out before attributing them to feline cognitive decline.

For both dogs and cats, urinating or defecating in the house may indicate diseases of the urinary or gastrointestinal tract or metabolic or hormonal concerns that result in polydipsia and polyuria. Interestingly, all of the dogs whose owners reported indoor elimination (Phase 1) were under 4 years of age, whereas the questionnaire (Phase 2) identified dogs across all age groups, with the greatest number in dogs > 9 years of age, an age when medical contributors may be more likely.

Noise sensitivity, separation anxiety, and aggression to people or other dogs have all been associated with painful conditions.1113 Dogs of any age with new or suddenly worsening signs of these behavior concerns should be evaluated for pain or other medical ailments. Very few owners volunteered concerns that their dogs were fearful of noises, so it was not possible to quantify a relationship between age and fear of noises in Phase 1. On the Phase 2 questionnaire, dogs that were fearful of noises ranged in age from 1 to > 9 years of age. Forty-four percent of owners of dogs 9 years of age or older identified their dogs’ fear of noises. The questionnaire did not ask when the fear of noises developed. The findings could reflect the cumulative effect of noise exposure and time or the previously reported association between noise sensitivity and painful conditions in these older patients.

A new onset of food aggression should prompt practitioners to rule out medical conditions (eg, hyperadrenocorticism) or medication side effects (eg, phenobarbital) as a cause for increased food motivation.

Overgrooming may be missed on physical examination of fractious or tense feline patients with alopecia of the ventral abdomen. Alopecia is a multifactorial concern with frequent medical contributors such as atopy, external parasites, or fungal infections.

“Yes” answers to any of these categorical survey questions should serve as red flags to practitioners to investigate further, especially with older patients whose behavior changes may be misattributed to aging.

The only question with no statistical difference between owner reporting and the survey was a screening questionnaire for signs of CCDS. Across both phases, only 7 dogs were identified by their owners as having signs of CCDS. Most of these dogs were 9 years of age or older, an age group in which CCDS is most identified but that made up only 7.7% of this study population.

Behavior problems damage the bonds between animals and their humans7 and contribute to caregiver fatigue.8,9 A previous study25 distinguished between owners who labeled a behavior “undesirable” or “problematic,” with the latter being more likely to want help, even if the behavior itself was within normal parameters for dogs or if the dog’s environment contributed to the behavior. While our study did not examine owner’s perceptions of unwanted behaviors, our findings support this distinction.

In our study, most pet owners were satisfied with their pets’ behavior. Owners of cats that seemed disoriented or howled at night were more likely to be dissatisfied and want help with the problem. Nighttime howling can be taxing for owners trying to get a full night’s sleep or relax in the evening hours.

House soiling in dogs was associated with unsatisfied owners but not with owners who wanted help. In contrast, owners of house-soiling cats were far more likely to be dissatisfied and want help. We propose that this may be related to owners’ greater understanding of the factors that contribute to indoor elimination in dogs (eg, left inside too long, missed the signal to go out) than they have for cats that seemingly have continuous access to a bathroom. Additionally, house-soiling dogs typically still eliminate outside regularly, which may not be true for affected cats that have no alternatives beyond other indoor locations. Dog owners may feel they have more control over the outcome than cat owners, giving them greater ability to cope.

Neither separation anxiety nor fear of noises was significantly associated with owners being dissatisfied. Separation anxiety and fear of noises are experienced by the dog, not the human. The dog’s reactions may not impact the satisfaction level of the owners unless severe enough for the dog to damage the house. It can be difficult for anyone to appreciate the significance of someone else’s fear or anxiety, especially of seemingly benign everyday situations. Owners may not recognize that separation anxiety and/or noise sensitivity can be extremely stressful for pets and erode their sense of well-being.

Canine aggression to humans or dogs was most strongly associated with owners who were dissatisfied with their pets and wanted help. This is consistent with the previously cited study,25 which reported owners of dogs that exhibited aggressive behavior viewed aggression as problematic and were 3 times more likely to want help. Owners of cats with aggression directed at humans were not more likely to be dissatisfied with their cats, yet were more likely to want help. It is possible that these cat owners were identifying low-level aggression they viewed as somewhat normal or occurring in expected contexts (eg, hissing when startled, swatting at the owner walking past) but still wanted help.

Owners who answer “yes” to the option for help may be more motivated clients who want veterinary advice. Pet owners who indicate they are satisfied with their pet may still want help with some aspect of their behavior. Pets of owners who express dissatisfaction yet decline help may be under relational tension with their owners and in danger of losing their homes. Their owners may have barriers at home that preclude them from seeking treatment. It is important for the veterinary team to not isolate owners who decline help, as we cannot know the pressures impacting their decision. Additionally, their thoughts may shift if their circumstances change and they feel supported by the team. These cases deserve veterinary guidance as much as any purely medical concerns that threaten the life or welfare of the patient. Including this information in the standard medical assessment would elevate the standard of patient care and a holistic approach to patient well-being.

In Phase 1, both dog and cat owners were far more likely than their veterinarians to bring up behavioral concerns. It is possible that despite specific directions to the contrary, study veterinarians did not ask about behavior as often as usual because they did not want to discourage owners from asking. We also don’t know whether the veterinarians would have asked about behavior if Phase 1 clients had not. However, the finding is consistent with other studies that concluded that veterinarians’ willingness to ask depends on their comfort responding to client questions and treating behavior concerns.3,4 A veterinarian’s confidence addressing medical or behavior conditions is likely to be influenced by knowing where to look for information and when and where to refer. Practitioners may be more likely to inquire about a patient’s behavior if instead of viewing it as an obligatory burden to fit into the pressing needs of a day, they see their expertise as a valuable service and schedule the time to work up the problem as they would for other diagnostic procedures.

Some practitioners have developed strong skills in diagnosing and treating behavior cases through a comprehensive behavior curriculum in veterinary school and/or continuing education opportunities. However, many veterinarians have not received enough behavior education to recognize or use current best-practice approaches to treat behavior cases.2224 Even those who had behavior coursework but no exposure to clinical behavior cases may lack the confidence and day 1 readiness expected in other veterinary disciplines. Veterinarians who do advise their clients about behavior problems run into obstacles that are less common in other fields. Friends, relatives, and other dog professionals may hold sway with strong opinions about how to “fix” a problem using outdated, folklore advice that is not supported by science and can make the situation worse. These factors can create doubt and confusion for practitioners who may have also grown up with these “truths,” yet strive to honor the veterinary code of “First, do no harm.”

The general-practice veterinarian does not need to be an expert in all behavioral modalities. Problem identification with referral is by itself a valuable service. Any practitioner can be an excellent source of help for their clients and engage with treatment as much or as little as they want on the basis of their available time, expertise, or confidence with an individual case.

The website for the American College of Veterinary Behaviorists hosts concise tables to aid in finding qualified help along a continuum from diplomates of the American College of Veterinary Behaviorists to credentialed, evidence-based trainers. Several US behavior specialty practices offer telehealth consultations, making diplomate-level care accessible independent of the client’s location. Practices can expand their services and improve efficiency by employing a Veterinary Technician Specialist in Behavior (VTS-Behavior) or a properly certified trainer to do targeted behavior therapy for the clinic’s behavior cases, work with patients on cooperative care training to reduce procedure time and improve the veterinary experience for patients, and host socialization classes for puppies and kittens.

Several factors could have impacted the results of this study. The study took place in a northern state in the US during overlapping times of year. Phase 1 was performed during the winter and spring seasons (December 2018 to April 2019), with Phase 2 following consecutively (April 2019 to September 2019). In northern climates, people and dogs tend to spend more time indoors in the winter months, with foot traffic and exposure to people and dogs increasing in the summer. Thunderstorms and fireworks occur far more commonly in the warmer months. Increased exposure may have made problems seem more immediate to owners and impacted Phase 2 results pertaining to fear of noises and aggression to dogs or people. Warmer weather seems unlikely to have increased reporting of house soiling for either dogs or cats, the significant cat results of disorientation/nighttime howling, or aggression directed at humans. Canine separation anxiety could be more common in summer months for dogs that rely heavily on a schedule or less common as families may spend more time at home. Atopy may be more common in summer months and could contribute to overgrooming. It is possible that owners of multiple pets may have been fatigued by answering multiple questionnaires and gave less accurate information. Data for Phase 2 was obtained via a written questionnaire and could have been impacted by owners’ reading comprehension skills. Veterinarians using a screening questionnaire in practice may wish to have staff read the survey questions for those owners who resist completing it in written form.

Breed type and sex/sexual status were not included in the individual data. The authors’ goal was for the study population to closely reflect daily life in veterinary practice. Each practice recorded data for the sequential wellness patients they examined without controlling for these factors. The results may have been skewed if the distribution was not comparable between the 2 phases.

Dog and cat owners were far more likely to identify behavior concerns through use of a screening questionnaire than they were to volunteer this information on their own. A screening questionnaire better identified behavior concerns across the pets’ life-spans, including for older pets in which medical contributors are most likely. A behavior screening questionnaire that can be completed by pet owners while they wait for the veterinarian can greatly enhance detection of behavior problems that may have medical implications and impact the security of the pet in its home. A screening questionnaire makes it feasible for veterinarians to assess behavior as a standard component of both wellness and ill patient examinations.

Supplementary Materials

Supplementary materials are posted online at the journal website: avmajournals.avma.org

Acknowledgments

Lisa Nelson, VMD, whose successful use of a behavior questionnaire in private practice, inspired this study.

Disclosures

The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.

Funding

The authors have nothing to disclose.

References

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    Kuntz K, Ballantyne KC, Cousins E, Spitznagel MB. Assessment of caregiver burden in owners of dogs with behavioral problems and factors related to its presence. J Vet Behav. 2023;64-65:41-46. doi:10.1016/j.jveb.2023.05.006

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    Lue TW, Pantenburg DP, Crawford PM. Impact of the owner-pet and client-veterinarian bond on the care that pets receive. J Am Vet Med Assoc. 2008;232(4):531-540. doi:10.2460/javma.232.4.531

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    Mills DS, Demontigny-Bédard I, Gruen M, et al. Pain and problem behavior in cats and dogs. Animals (Basel). 2020;10(2):318. doi:10.3390/ani10020318

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    Amadei E, Pierantoni L. Case report: noise and thunderstorm sensitivity in a dog with chronic pain. J Vet Behav. 2022;48:79. doi:10.1016/j.jveb.2021.06.010

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    McAuliffe LR, Koch CS, Serpell J, Campbell KL. Associations between atopic dermatitis and anxiety, aggression, and fear-based behaviors in dogs. J Am Anim Hosp Assoc. 2022;58(4):161-167. doi:10.5326/JAAHA-MS-7210

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    Suñol A, Perez-Accino J, Kelley M, Rossi G, Schmitz SS. Successful dietary treatment of aggression and behavioral changes in a dog. J Vet Behav. 2020;37:56-60. doi:10.1016/j.jveb.2020.04.009

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    Becuwe-Bonnet V, Belanger MC, Frank D, Parent J, Hélie P. Gastrointestinal disorders in dogs with excessive licking of surfaces. J Vet Behav. 2012;7(4):194-204. doi:10.1016/j.jveb.2011.07.003

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    Wiech K, Tracey I. The influence of negative emotions on pain: behavioral effects and neural mechanisms. Neuroimage. 2009;47(3):987-994. doi:10.1016/j.neuroimage.2009.05.059

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    • Export Citation
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    Menor-Campos DJ, Williams JM, Gazzano A, Mariti C. Student veterinarians’ ability to recognise behavioural signs of stress in dogs. J Vet Behav. 2022;50:46-52. doi:10.1016/j.jveb.2021.12.002

    • Search Google Scholar
    • Export Citation
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    Bergman L, Hart BL, Bain M, Cliff K. Evaluation of urine marking by cats as a model for understanding veterinary diagnostic and treatment approaches and client attitudes. J Am Vet Med Assoc. 2002;221(9):1282-1286. doi:10.2460/javma.2002.221.1282

    • Search Google Scholar
    • Export Citation
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    Roshier AL, McBride EA. Veterinarians’ perceptions of behaviour support in small-animal practice. Vet Rec. 2013;172(10):267. doi:10.1136/vr.101124

    • Search Google Scholar
    • Export Citation
  • 21.

    Hevern ME. Welfare worries: a preliminary, cross-sectional study of general practice, small animal veterinarians perceptions and management of canine and feline behaviour problems. Aust Vet J. 2022;100(8):377-387. doi:10.1111/avj.13168

    • Search Google Scholar
    • Export Citation
  • 22.

    Calder CD, Albright JD, Koch C. Evaluating graduating veterinary students’ perception of preparedness in clinical veterinary behavior for “Day-1” of practice and the factors which influence that perception: a questionnaire-based survey. J Vet Behav. 2017;20:116-120. doi:10.1016/j.jveb.2017.05.001

    • Search Google Scholar
    • Export Citation
  • 23.

    Golden O, Hanlon AJ. Towards the development of day one competences in veterinary behaviour medicine: survey of veterinary professionals experience in companion animal practice in Ireland. Ir Vet J. 2018;71(12):12. doi:10.1186/s13620-018-0123-3

    • Search Google Scholar
    • Export Citation
  • 24.

    Roshier AL, McBride EA. Canine behaviour problems: discussions between veterinarians and dog owners during annual booster consultations. Vet Rec. 2013;172(9):235. doi:10.1136/vr.101125

    • Search Google Scholar
    • Export Citation
  • 25.

    Pirrone F, Pierantoni L, Mazzola SM, Vigo D, Albertini M. Owner and animal factors predict the incidence of, and owner reaction toward, problematic behaviors in companion dogs. J Vet Behav. 2015;10(4):295-301. doi:10.1016/j.jveb.2015.03.004

    • Search Google Scholar
    • Export Citation

Supplementary Materials

  • Figure 1

    Dog owners presenting patients for routine annual examinations report far fewer behavior concerns voluntarily than when using a screening questionnaire. Q1 = House soiling; *P < .0001. Q2 = Disoriented/confused. Q3 = Separation anxiety; *P = .028. Q4 = Fear of noises; *P < .001. Q5 = Aggression to humans; *P = .0046. Q6 = Aggression to dogs; *P = .0001. Q7 = Satisfied. Q8 = Want help. Any = Any concern identified; *P < .0001.

  • Figure 2

    Cat owners presenting patients for routine annual examinations report far fewer behavior concerns voluntarily than when using a screening questionnaire. Questions 3 and 4 were discarded. Q1 = House soiling; *P = .034. Q2 = Disorient/howl; *P = .0034. Q5 = Aggression to humans; *P = .0046. Q6 = Overgroom; *P = .018. Q7 = Satisfied. Q8 = Want help. Any = Any concern identified; *P < .0001.

  • Figure 3

    Data showing the canine questionnaire to be far better than voluntary owner reporting at identifying behavior concerns in older dogs. Few dogs were < 1 year of age, so this category is excluded. Any = Any concern identified. I1Q1 = House soiling. I2Q2 = Disoriented/confused. I3Q3 = Separation anxiety. I4Q4 = Fear of noises. I5Q5 = Aggression to humans. I6Q6 = Aggression to dogs.

  • Figure 4

    Data showing the feline questionnaire to be far better than voluntary owner reporting at identifying behavior concerns in older cats. Few cats were < 1 year of age, so this category is excluded. Questions 3 and 4 were discarded. Q1 = House soiling. Q2 = Disorient/howl. Q5 = Aggression to humans. Q6 = Overgroom. Any = Any concern identified.

  • 1.

    Creevy KE, Grady J, Little SE, et al. 2019 AAHA Canine Life Stage Guidelines. J Am Anim Hosp Assoc. 2019;55(6):267-290. doi:10.5326/JAAHA-MS-6999

    • Search Google Scholar
    • Export Citation
  • 2.

    Quimby J, Gowland S, Carney HC, DePorter T, Plummer P, Westropp J. 2021 AAHA/AAFP Feline Life Stage Guidelines. J Feline Med Surg. 2021;23(3):211-233. doi:10.1177/1098612X21993657

    • Search Google Scholar
    • Export Citation
  • 3.

    Kogan LR, Hellyer PW, Rishniw M, Schoenfeld-Tacher R. Veterinary behavior: assessment of veterinarians’ training, experience, and comfort level with cases. J Vet Med Educ. 2020;47(2):158-169. doi:10.3138/jvme.0318-035r1

    • Search Google Scholar
    • Export Citation
  • 4.

    Patronek GJ, Dodman NH. Attitudes, procedures, and delivery of behavior services by veterinarians in small animal practice. J Am Vet Med Assoc. 1999;215(11):1606-1611.

    • Search Google Scholar
    • Export Citation
  • 5.

    Salman MD, Hutchison J, Ruch-Gallie R, et al. Behavioral reasons for relinquishment of dogs and cats to 12 shelters. J Appl Anim Welf Sci. 2000;3(2):93-106. doi:10.1207/S15327604JAWS0302_2

    • Search Google Scholar
    • Export Citation
  • 6.

    Pegram C, Gray C, Packer RMA, et al. Proportion and risk factors for death by euthanasia in dogs in the UK. Sci Rep. 2021;11(1):9145. doi:10.1038/s41598-021-88342-0

    • Search Google Scholar
    • Export Citation
  • 7.

    Kwan JY, Bain MJ. Owner attachment and problem behaviors related to relinquishment and training techniques of dogs. J Appl Anim Welf Sci. 2013;16(2):168-183. doi:10.1080/10888705.2013.768923

    • Search Google Scholar
    • Export Citation
  • 8.

    Buller K, Ballantyne KC. Living with and loving a pet with behavioral problems: pet owners’ experiences. J Vet Behav. 2020;37:41-47. doi:10.1016/j.jveb.2020.04.003

    • Search Google Scholar
    • Export Citation
  • 9.

    Kuntz K, Ballantyne KC, Cousins E, Spitznagel MB. Assessment of caregiver burden in owners of dogs with behavioral problems and factors related to its presence. J Vet Behav. 2023;64-65:41-46. doi:10.1016/j.jveb.2023.05.006

    • Search Google Scholar
    • Export Citation
  • 10.

    Lue TW, Pantenburg DP, Crawford PM. Impact of the owner-pet and client-veterinarian bond on the care that pets receive. J Am Vet Med Assoc. 2008;232(4):531-540. doi:10.2460/javma.232.4.531

    • Search Google Scholar
    • Export Citation
  • 11.

    Lopes Fagundes AL, Hewison L, McPeake KJ, Zulch H, Mills DS. Noise sensitivities in dogs: an exploration of signs in dogs with and without musculoskeletal pain using qualitative content analysis. Front Vet Sci. 2018;5:17. doi:10.3389/fvets.2018.00017

    • Search Google Scholar
    • Export Citation
  • 12.

    Mills DS, Demontigny-Bédard I, Gruen M, et al. Pain and problem behavior in cats and dogs. Animals (Basel). 2020;10(2):318. doi:10.3390/ani10020318

    • Search Google Scholar
    • Export Citation
  • 13.

    Amadei E, Pierantoni L. Case report: noise and thunderstorm sensitivity in a dog with chronic pain. J Vet Behav. 2022;48:79. doi:10.1016/j.jveb.2021.06.010

    • Search Google Scholar
    • Export Citation
  • 14.

    McAuliffe LR, Koch CS, Serpell J, Campbell KL. Associations between atopic dermatitis and anxiety, aggression, and fear-based behaviors in dogs. J Am Anim Hosp Assoc. 2022;58(4):161-167. doi:10.5326/JAAHA-MS-7210

    • Search Google Scholar
    • Export Citation
  • 15.

    Suñol A, Perez-Accino J, Kelley M, Rossi G, Schmitz SS. Successful dietary treatment of aggression and behavioral changes in a dog. J Vet Behav. 2020;37:56-60. doi:10.1016/j.jveb.2020.04.009

    • Search Google Scholar
    • Export Citation
  • 16.

    Becuwe-Bonnet V, Belanger MC, Frank D, Parent J, Hélie P. Gastrointestinal disorders in dogs with excessive licking of surfaces. J Vet Behav. 2012;7(4):194-204. doi:10.1016/j.jveb.2011.07.003

    • Search Google Scholar
    • Export Citation
  • 17.

    Wiech K, Tracey I. The influence of negative emotions on pain: behavioral effects and neural mechanisms. Neuroimage. 2009;47(3):987-994. doi:10.1016/j.neuroimage.2009.05.059

    • Search Google Scholar
    • Export Citation
  • 18.

    Menor-Campos DJ, Williams JM, Gazzano A, Mariti C. Student veterinarians’ ability to recognise behavioural signs of stress in dogs. J Vet Behav. 2022;50:46-52. doi:10.1016/j.jveb.2021.12.002

    • Search Google Scholar
    • Export Citation
  • 19.

    Bergman L, Hart BL, Bain M, Cliff K. Evaluation of urine marking by cats as a model for understanding veterinary diagnostic and treatment approaches and client attitudes. J Am Vet Med Assoc. 2002;221(9):1282-1286. doi:10.2460/javma.2002.221.1282

    • Search Google Scholar
    • Export Citation
  • 20.

    Roshier AL, McBride EA. Veterinarians’ perceptions of behaviour support in small-animal practice. Vet Rec. 2013;172(10):267. doi:10.1136/vr.101124

    • Search Google Scholar
    • Export Citation
  • 21.

    Hevern ME. Welfare worries: a preliminary, cross-sectional study of general practice, small animal veterinarians perceptions and management of canine and feline behaviour problems. Aust Vet J. 2022;100(8):377-387. doi:10.1111/avj.13168

    • Search Google Scholar
    • Export Citation
  • 22.

    Calder CD, Albright JD, Koch C. Evaluating graduating veterinary students’ perception of preparedness in clinical veterinary behavior for “Day-1” of practice and the factors which influence that perception: a questionnaire-based survey. J Vet Behav. 2017;20:116-120. doi:10.1016/j.jveb.2017.05.001

    • Search Google Scholar
    • Export Citation
  • 23.

    Golden O, Hanlon AJ. Towards the development of day one competences in veterinary behaviour medicine: survey of veterinary professionals experience in companion animal practice in Ireland. Ir Vet J. 2018;71(12):12. doi:10.1186/s13620-018-0123-3

    • Search Google Scholar
    • Export Citation
  • 24.

    Roshier AL, McBride EA. Canine behaviour problems: discussions between veterinarians and dog owners during annual booster consultations. Vet Rec. 2013;172(9):235. doi:10.1136/vr.101125

    • Search Google Scholar
    • Export Citation
  • 25.

    Pirrone F, Pierantoni L, Mazzola SM, Vigo D, Albertini M. Owner and animal factors predict the incidence of, and owner reaction toward, problematic behaviors in companion dogs. J Vet Behav. 2015;10(4):295-301. doi:10.1016/j.jveb.2015.03.004

    • Search Google Scholar
    • Export Citation

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